ATI Fundamentals Leadership Final Exam Prep

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A. Pernicious anemia B. Dehydration C. Prostate enlargement D. Bladder infection - d. Bladder infection A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should nurse take when obtaining the specimen? A. Use sterile swab to obtain the specimen B. Place specimen in sterile container C. Label the paper bag in which specimen container is placed D. Send specimen container immediately to the lab - d. Send specimen immediately to lab A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? A. One nurse lifting as the client pushes with his feet B. Two nurses lifting the client under the shoulders C. One nurse lifting the client's legs as the client uses a trapeze bar D. Two nurses using a friction reducing device - d. Two nurses using a friction reducing device A nurse is planning care for an older adult client who is at risk for developing pressure ulcer. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed B. Apply cornstarch to keep sensitive skin areas dry C. Massage the skin over the client's body prominences D. Elevate the head of the bed no more than 45 degrees - a. Use a transfer device to lift the client up in bed A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to inability to swallow. Which of the following is the priority action by the nurse? A. Observe client's respiratory status B. Elevate the head of client's bed from 30 to 45 C. Monitor intake and output every 8 hours D. Check residual volume every 4-6 hours - b. Elevate head of bed from 30 to 45 degrees to reduce risk of aspiration A home heath nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (select all that apply) A. Bathtub with rails B. Electric cords behind furniture C. Raised toilet seats D. Water heater temp 130 f E. Throw rugs - d. Water heater E. Throw rugs A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick release tie B. Ensure four fingers fit under restraints to prevent constriction C. Secure the restraints to the lowest bar on the side rail D. Anticipate removing the restraints every 4 horus - a. Secure the restraints using a quick release tie A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (select all that apply) A. Report of feeling pressure B. Tenderness over symphysis pubis C. Distended badder D. Voiding 30 ml frequently E. Dysuria - a. Report of feeling pressure B. Tenderness over symphysis pubis C. Distended bladder d. Voiding 30ml frequently A nurse is caring for a client who has fallen while getting out of bed and states "i'm okay. I guess i should have called for help to the bathroom." after assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. There were no injuries sustained B. An incident report was completed C. An incident report was forwarded to risk management D. The provider was notified - d. The provider was notified A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (tpn) solution is not infusing. The nurse should monitor the client for which of the following conditions? A. Excessive thirst and urination B. Shakiness and diaphoresis C. Fever and chills D. Hypertension and crackles - b. Shakiness and diaphoresis A nurse is caring for a client who receives intermittent enteral feedings through an ng tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? A. Confirm placement B. Remove gastric acid that might cause dyspepsia C. Determine the client's electrolyte balance D. Identify delayed gastric emptying - d. Identify delayed gastric emptying- if delayed should avoid feeding and causing distention A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust water temp to feel hot B. Apply 4-5 ml of liquid soap to hands C. Hold hands higher than elbows D. Rub hands and arms to dry - b. Apply 4-5 ml of liquid soap to hands A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for: A. Steoatorrhea B. Blood C. Bacteria D. Parasites - b. Blood A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. Vital signs measurement B. The client's self report of pain C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure - b. Client's self report A nurse is receiving change of ship report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? A. Critically analyze client data to determine priorities B. Collect and organize client data C. Set client centered, measurable and realistic goals D. Determine effectiveness of interventions - b. Collect and organize client data A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A. Hypotension B. Numbness C. Shivering D. Reduced blood viscosity - c. Shivering A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. Call the client's provider B. Assess client C. Notify the nurse manager D. Complete incident report - b. Assess client A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction tow to three times whit a 60 second pause between passes B. Perform chest pt prior to suctions C. Lubricate suction catheter tip with sterile saline D. Hyperventilate the client on 100% oxygen prior to suctioning - a. Suction two to three times with a 60 second pause between passes A nurse is caring for a client who has mrsa in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? A. Wear n95 respirator mask B. Wear sterile gloves C. Wear clean gloves D. Wear protective eyewear - c. Wear clean gloves A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. Upper respiratory infections B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying - c. Atelectasis- from prolonged bed rest A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station? A. A client who sustained a head injury and is having periods of confusion B. A client who reports severe migraine headache C. A client who has a suspected diagnosis of tuberculosis D. A client who has a history of atrial fibrillation and is on continuous ecg monitoring - a. Client who sustained a head injury and having periods of confusion A nurse is caring for a client who has an ng tube. The nurse tests the ph of the secretions to determine that the tube is correctly place. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0 - b. 4.0 A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I will walk briskly for 30 minutes before bed B. I will no longer have a glass of wine before bed time C. I will have a cup of hot cocoa immediately before bedtime D. I will do my muscle relaxation techniques each afternoon - b. I will no longer have a glass of wine before bedtime- can act as diuretic and disrupt sleep cycle A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions take by the assistive personnel while the client is sleeping should prompt the nurse to intervene? A. Closes door to client's room B. Measures the client's vital signs routinely C. Asks a group of nurses in the hall to speak quietly D. Flushes the client's toilet after emptying the urinary catheter's drainage bag - d. Flushes client's toilet A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? A. Placing a sterile dressing 5cm (2in) from the border of the sterile field B. Holder a sterile item at just above waist level C. Opening a sterile package over the middle of the sterile field D. Opening the sterile tray by first unfolding the flap farthest from his body - c. Opening a sterile package over the middle of sterile field A nurse is implementing a bowel training program for a client. For the program to be effective. The nurse should take the client to the toilet at which of the following times? A. When the client has the urge to defecate B. Every 2 hours while the client is away C. Immediately before the client has a meal D. After the client feels abdominal cramping - a. When the client has the urge to defecate A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? A. Lemon sherbet B. Plain yogurt C. Cranberry juice D. Carrot juice - c. Cranberry juice A nurse is admitting a client who is arriving back to the unit from the pacu following hips arthroplasty. Which of the following tasks should the nurse assign the the ap? A. Obtain initial vital signs B. Determine if the client is in need of pain medication C. Record amount of urine in the catheter drainage bag D. Instruct client on use of incentive spirometer - c. Record amount of urine A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90 degree angle to the bed B. Lock the wheels of the bed and the wheelchair C. Acquire the help of several people to lift the client D. Elevate the bed to a position of comfort for the nurse - b. Lock the wheels of the bed and wheelchair A nurse is caring for a client who has active pulmonary tuberculosis. The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiologic department for a chest x-ray? A. Ask x-ray tech to come to clients room to obtain portable x-ray B. Have client wear a mask C. Notify the x-ray department that the client requires airborne precautions D. Wear a filtration mask and gloves during t - b. Have client wear a mask A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as cases of constipation? (select all that apply) A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake D increased fiber in the diet E. Increased activity - a. Excessive laxative useb. Ignoring urge to defecate C. Inadequate fluid intake A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? A. Call family and ask them to stay with client B. Move client to room closer to nurses' station C. Apply wrist and leg restraints to client D. Administer medication to sedate client - b. Move client closer to nurses' station A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? A. Contract pelvic muscles B. Take a sip of water C. Exhale slowly D. Bear down - d. Bear down A nurse is preparing to administer three liquid medications to a client who has an ng feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix three meds together prior to administering B. Dilute each medication with 10ml of tap water C. Maintain head of bed in.a flat position for 30 minutes following med administration D. Flush ng tube with 30 ml of water immediately following med administration - d. Flush ng tube A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Use a stiff toothbrush to clean client's teeth B. Use a thumb and index finger to keep the client's mount open C. Turn client on side before starting oral care D. Apply petroleum jelly to client's lips after oral care - c. Turn client on side before starting oral care A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (select all that apply) A. Shoulders droop B. Facial muscles relax C. Respiratory rate increases D. Pulse is within expected range E. Client draws his legs up into fetal position - a. Shoulders droop B. Facial muscles relax D. Pulse is within expected range A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen B. Administer prescribed analgesic medication C. Encourage coughing and deep breathing D. Raise the head of bed - d. Raise the head of bed- allows for increased expansion of lungs A nurse instructs a female client about collecting a midstream urine sample. Which of the following client states indicates an understanding of the procedure? A. I'll urinate a little then stop B. I'll use the cleansing wipe from from front to back C. I;ll clean the inside of the container with a wipe D. I'll use each cleansing wipe twice - b. I'll use the cleansing wipe from front to back A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine kinase B. Troponin C. Total bilirubin D. Albumin - d. Albumin A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plant to use to prevent the client from developing plantar flexion contractors? A. Trochanter roll B. Sheepskin heel pad C. Abduction pillow D. Foot board - d. Footboard A nurse prepares an injection of morphine (duramorph) to administer to a patient who reports pain. Prior to administering the medication, the nurse is called to another room to assist another patient onto a bedpan. She asks the second nurse to give the injection. Which of the following actions should the second nurse take? A Offer to assist the patient needing the bedpan. B Administer the injection prepared by the other nurse. C Prepare another syringe and administer the injection. D Tell the p - a. Offer to assist the patient needing the bedpan. The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. It will be most important for the nurse to A Report this finding to the provider B Note this finding in the client's record C Revise the plan of care D Remove the nursing diagnosis from the plan - c. Revise plan of care You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A An increased appetite B An increased heart rate C A decrease in perspiration D A decrease in respiratory rate - b. An increased heart rate The nurse is caring for a patient with bacterial pneumonia. The effectiveness of the patient's oxygen therapy can be best determined by which indicator of oxygenation? A Absence of cyanosis B Patient's respiratory rate C Arterial blood gas (abg) values D Patient's level of consciousness - c. Arterial blood gas (abg) values A nurse is teaching a patient how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? A "flush the tube before and after each medication." B "administer your medications with your enteral feeding." C "administer tablets through the tube slowly." D "mix all the crushed medications prior to dissolving in water." - a. Flush the tube before and after each med What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. A Change the catheter daily B Provide perineal care at least once a day C Maintain a closed drainage system D Encourage the patient to drink 3000 ml fluids daily E Recommend health care provider prescribe antibiotics - b. Provide perineal care at least once a day C. Maintain a closed drainage system D. Encourage the patient to drink 3000 ml fluids daily A nurse is preparing to administer a medication to a patient. The medication was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication? (select all that apply) A 0905 B 0825 C 1000 D 0840 E 0935 - a. 0905 D. 0840 The nurse is called to the patient's room by another nurse. When the second nurse arrives at the room, she discovers that a fire has occurred in the patient's waste basket. The first nurse has removed the patient from the room. What is the second's nurse next action? A Evacuate the unit B Extinguish the fire C Confine the fire D Activate the fire alarm - d. Activate the alarm Which mental status change may occur when a patient with pneumonia is first experiencing hypoxia? A Coma B Apathy C Irritability D Depression - c. Irritability A patient admitted with pneumonia and dementia has attempted several times to pull out the iv and foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft restraints. Which nursing action is most appropriate? A Perform circulation checks to bilateral upper extremities each shift B Attach the ties of the restraints to the bed frame C Reevaluate the needs for restraints and document weekly D Ensure the restraint prescription has been signed by the health car - b. Attach the ties of the restraints to the bed frame Tpn is prescribed for a patient with chron's disease. What indicates to the nurse that the tpn has been effective? A Has met nutritional needs B Is not in metabolic acidosis C Is hydrated D Is in negative nitrogen balance - a. Has met nutritional needs A nurse is working with a newly hired nurse who is administering medications to patients. Which of the following actions by the newly hired nurse indicates an understanding of medication error prevention? A Taking all medications out of the unit-dose wrappers before entering the patient's room. B Checking with the provider when a single dose requires administration of multiple tablets. C Administering a medication, then looking up the usual dosage range. D Relying on another nurse to clarify a - b. Checking with he provider when a single dose requires administration of multiple tablets The nurse is teaching the patient how to care for an ileostomy. The patient asks the nurse how long to wear the pouch before changing it. What should the nurse tell the patient? A "the pouch is changed only when it leaks" B "you can wear the pouch for about 4 to 7 days>" C "you should change the pouch every evening before bedtime." D "it depends on your activity level and your diet." - b. You can wear the pouch for about 4-7 days The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? A Stage i pressure ulcer B Stage 2 pressure ulcer C Stage 3 pressure ulcer D Stage 4 pressure ulcer - b. Stage 2 pressure ulcer When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse expects that the client would be exhibiting what behaviors? A Objective and rational problem solving B Tension reduction activities and then problem solving C Anger management strategies with no problem solving D Minimal functioning with new problems developing - d. Minimal functioning with new problems developing A nurse is providing teaching to an older adult patient to promote adherence with medication administration. Which of the following instructions should the nurse include? (select all that apply) Multiple answers: multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...show more A Adjust the dose according to daily weight. B Place pills in daily pill holders. C Provide liquid forms if the patient has difficulty swallowing pills. D Ask a rel - b. Place pills in daily pill holders. C. Provide liquid forms if the patient has difficulty swallowing pills. D. Ask a relative/friend to assist periodically Total parenteral nutrition (tpn) is prescribed for the patient who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the tpn? A Administer tpn through a nasogastric or gastrostomy tube B Handle tpn using strict aseptic technique C Auscultate for the presence of bowel sounds prior to administration of tpn D Designate a peripheral iv site for tpn administration - b. Handle tpn using strict aseptic technique A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Which of the following should be included in the instructions? A Apply petroleum jelly around the nares B Assure the patient and their family that the patient can still smoke C Check the position of the nasal cannula frequently D Remove the nasal cannula during meal time - c. Check the position of the nasal cannula frequently A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: A Administering a sleep aid B Synchronizing the medication, treatment, and vital signs schedule C Encouraging the patient to exercise immediately before sleep D Discussing with the patient the benefits of beginning a long-term nighttime medication regimen - b. Synchronizing the medication, treatment, and vital signs schedule When teaching the patient with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the patient to report which symptoms to the health care provider (hcp)? Select all that apply. A Cloudy urine for the first few days B Blood in the urine C Rash D Mild nausea E Fever above 100 degrees f (37.8 degrees c) F Urinating every 3 to 4 hours - b. Blood in the urine C. Rash E. Fever above 100 degrees f A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? A Regulating the body processes through electrical control B Shocking the patient when an undesirable response is elicited C Monitoring the body processes for the therapist to interpret D Translating the signals of body processes into observable forms - d. Translating the signals of body processes into observable forms A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? A Regulating the body processes through electrical control B Shocking the patient when an undesirable response is elicited C Monitoring the body processes for the therapist to interpret D Translating the signals of body processes into observable forms - b. Document the patient's response to pain medication A nurse in a provider's office is caring for a patient who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the patient's difficulty sleeping. (select all that apply) A Does your lack of sleep interfere with your ability to function during the day? B Do you feel confused in the late afternoon? C Do you drink coffee tea or other caffeinated drinks? If so how many cups per - a. Does your lack of sleep interfere with your ability to function during the day? C. Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? E. Tell me about your personal stress you are experiencing The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? A Tell the charge nurse that the nurse is going to lunch B Verify that the charge nurse has assigned someone to take care of the patient C Give the charge nurse information about what care should be given while the nurse is at lunch D Remind the charge nurse about the patient's history and current - c. Give the charge nurse information about what care should be given while the nurse is at lunch The nurse should perform passive range-of-motion (rom) exercises on which patients? Select all that apply Multiple answers: multiple answers are accepted for this question A Has septic joints B Has temporary loss of consciousness C Is unconscious D Has plantar flexion of the foot E Has supination of the hand - b. Has temporary loss of consciousness C. Is unconscious Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery? A Age over 75 years B Poorly controlled diabetes C History of one myocardial infarction D Chronic peripheral vascular disease - b. Poorly controlled diabetes The nurse is assessing a client with dark skin for the presence of a stage 1 pressure ulcer (injury). Which is the best approach to making this assessment? A Use a fluorescent light source to assess the skin B Inspect the skin only when the braden score is above 12 C Look for skin color that is darker than the surrounding tissue D Avoid touching the skin during inspection - c. Look for skin color that is darker than the surrounding tissue A nurse is preparing to feed a patient via ng tube. Which of the following is the nurse's highest priority before initiating the feeding? A Check the feeding container for expiration B Confirm the patient does not have diarrhea C Make sure the client is alert and oriented D Verify placement of the ng tube - d. Verify placement of the ng tube During meal time the nurse notices the patient's hands are holding the throat. Which patient situation requires immediate action by the nurse? A The patient has a high-pitched inspiratory stridor B The patient is talking and gagging C The patient is coughing D The patient is not making any sounds - d. The patient is not making any sounds A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: A Maturational B Situational C Sociocultural D Posttraumatic - b. Situational During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: A Cataplexy B Insomnia C Narcolepsy D Sleep apnea - d. Sleep apnea While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? A Sanguineous B Serosanguineous C Serous D Purosanguineous - b. Serosanguineous Which patient has a naturally acquired active immunity? A The adult who received immunizations B The infant whose immunity was transferred from the mother to the infant. C The child is recovering from a childhood disease that conferred immunity. D The adult who received gamma globulin after exposure to hepatitis. - c. The child is recovering from a childhood disease that conferred immunity A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: A Adding a daytime nap B Allowing the child to sleep longer in the morning C Maintaining the child's home sleep routine D Offering the child a bedtime snack - c. Maintaining the child's home sleep routine Which of the following is an example of an active listening behavior? A Taking frequent notes B Asking for more details C Leaning toward the patient D Sitting comfortably with legs crossed - c. Leaning toward the patient The nurse is reviewing hand hygiene with uaps. Which statement by the uap requires further instructions? A "i will wash my hands before and after care and i wear gloves with each patient." B "i wash my hands when they are visible soiled." C "i will not wear artificial nails when providing care." D "it is ok to use the alcohol based products outside of the patient's room when entering and leaving the area." - b. I wash my hands when they are visibly soiled Which of the following describes the difference between dehiscence and evisceration? A With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. B Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent C Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more laye - a. With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal visceral from the incision site The client was found lying on the floor next to the bed. Once urgent care is provided, the nurse completes an incident report. Which statements would be inappropriate to include in the report? Select all that apply A. The client fell out of bed B. No bruises or injuries are noted on the client C. The client apparently climbed over the side rails when the nurse was out of the room D. The physician was notified that the client was found lying on the floor next to the bed E. The client is alert an - a. The client fell out of bed C. The client apparently climbed over the side rails when the nurse was out of the room Which are complications of bed rest? Select all that apply. A Extremity contractures B Decreased dependency C Diarrhea D Pneumonia E Pressure ulcers F Thrombi G Urinary calculi - a. Extremity contractures D. Pneumonia E. Pressure ulcers F. Thrombi G. Urinary calculi The nurse is planning the care of a frail, immobile, elderly patient. Which of the following is the best treatment or prevention to protect the patient's skin? A Administer fluid boluses as directed by the healthcare provider B Assisting the patient to sit in a chair three times a day C Offering the patient six small meals a day D Turning the patient at least every 2 hours - d. Turning patient at least every 2 hours What is the correct method for turning an adult patient brought to the er with a suspected spinal cord injury? . A Ask the patient to assist with the turn by holding the siderails of the bed B Place a draw sheet under the patient to assist with turning C Request help from another nurse to perform logrolling technique D Use a mechanical lift for safe turning and protecting the nurse's back - c. Request help from another nurse to perform logrolling technique A nurse is assess the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? . A Presence of associated symptoms B Location of the pain C Pain quality D Aggravating and relieving factors - a. Presence of associated symptoms Which of the following is an example of a problem that nurses can treat independently? A Hemorrhage B Nausea C Fracture D Infection - b. Nausea The nurse must transfer a dependent patient from a bed to a gurney. Which action by the nurse will be safest for the patient and nurse? A Adjust the height of the bed B Avoid movements that twist the spine C Keep the patient close to the nurse's body when lifting D Obtain an appropriate mechanical lift device - d. Obtain an appropriate mechanical lift device